The recently launched “Happiness Therapy” pilot of the Delhi Government at Guru Teg Bahadur (GTB) Hospital has, once again, emphasized the chasm between what our policy makers are prepared to deliver, and what is needed on ground.
The GTB pilot was launched by Delhi Health Minister Satyendra Jain in the Maternal and Child Health wing, to be emulated in all wards, except the Emergency and Intensive Care Units, for the speedy recovery and better healing of patients. The program aims at improving patient experience, and at fostering a better relationship between patients and their caregivers in hospital.
The ill-conceived, hastily-launched pilot can only be credited to intellectual bankruptcy of the powers that be: there is an insurmountable disconnect between those who are responsible for designing healthcare delivery, and those who actually deliver healthcare.
Real-time Tracking of Logistics Within the Hospital
As is true for most publicly provided healthcare systems, and indeed all of those within India, limited resources cater to an unlimited demand, of a burgeoning population. Any decisions about health care delivery, especially for the over stressed government hospital, must be extremely cognizant about the efficient allocation of scarce resources. Doctors and healthcare workers definitely head the list of over stressed resources.
If you’ve ever walked into a public health facility in Delhi, you would have been overwhelmed by the sheer number of people there. Wait times of over two hours for a two and half minute consult, the harried doctor, the ever-missing nurse: the narrative cuts across institutions, medical colleges and stand-alone Mohalla clinics. The general atmosphere is one of chaos, and I am saying it out loud, the average doctor in the OPD is merely struggling to perform a rapid triage. To sort out those patients who need emergent care from those who will probably be okay with a little less attention, and those who will need to be sent home with a hurriedly scribbled prescription.
The average resident doctor works for a super human 80-100 hours a week (no, the 40 hour work week spoken of in Parliament is a myth, always has been).
And if things haven’t changed dramatically from when I was a resident at GTB, grapples very often with lack of running water to scrub for surgery, clogged toilets and dysfunctional air conditioners. Add to this the looming specter of violence, a threat that now follows the doctor home, and you have an individual overworked, overstressed and constantly on edge. Life is no different for the nurses.
And if you were to look at often-on-the-blink equipment, machinery that has not been serviced and updated over years, and MRI machine which will be acquired soon (GTB got funds for an MRI in 2016, its yet to be installed), the situation on ground zero does seem impossible.
Individualised compassionate care in these settings remains more of a future vision than a daily reality, the sheer numbers make it so, so does the lack of actual physical resources.
For the much-touted Mohalla clinics with providers struggling with the logistics of health care delivery, this gap is even wider.
In circumstances as bleak, asking the doctor and paramedical staff to spare half an hour to dance with the patients does reek of a complete lack of insight. It is only rational, then, that the residents of GTB have completely refused to be part of the song and dance routine proposed by the Delhi government. The proposal does not offer a solution for all that plagues the healthcare system, in fact, it adds insult to injury.
For doctors, nurses, healthcare workers and patients alike.
The Lack of Insight
Yes, patients are concerned with many aspects of health care beyond health outcomes. Their primary concern, of course, is to feel better, but they do care about other things on their road to health. But if you were to look at all the determinants that influence the patients’ quality of life when in a hospital, the parameters most individuals will focus upon will be waiting time, promptness of treatment, availability of diagnostic tests and medication, availability and accessibility of staff providing care (consultant doctors, specialist nurses and physiotherapists) top the list. These are all actually healthcare delivery process attributes. They are measurable, quantifiable, and optimal ratios for each of these are available. And in the case of our hospitals, seriously deficient on all counts.
Ward rounds are sacrosanct. It’s when the various stakeholders involved in healthcare delivery talk to each other, strategise on further management of the patient. Nurses give their input, residents are asked questions of clinical relevance.
There is a reason why in hospitals associated with medical colleges, they are called teaching rounds.
The average doctor learns more on these rounds than in classrooms. To reduce them to a song and dance routine, would be, for lack of a better word, a travesty.
Basics First
Before we emphasize on spiritual care and emotional support to the new mothers, are we sure that these ladies have an acceptable rate of wound infection? Did they get decent hygienically prepared hot meals? Did each of the new mothers have a bed to themselves, or were they squeezed three-on-one? Were they counseled on breast feeding technique, did they have access to a caregiver who would prepare them to take care of the newborn? And did we ensure that the babies that were lost, were not lost because of lack of basic facilities, sanitation, unavailable drugs?
It is only when the fundamentals are met with can we deal with other end of the clinical complexity spectrum.
Few recent trends in health care delivery have more power to improve population health, patient and provider experience, than the infusion of much needed cash into the system.
Recruit more doctors and healthcare workers, including nurses, retain the super specialists, upgrade their skills, provide them with the technology and infrastructure to enable rational, thoughtful healthcare delivery.
While it is easy to have a knee-jerk "Lets ape the hospital in Brazil where doctors and nurses dance to make patients feel better, ” we also need to be cognizant of the socio-cultural dynamics and economic situation of the people we hope to serve. Decisions in healthcare, whether about treatment protocols or patient care, have to be based on evidence from trials and formal meta-analyses. The Discrete Choice Experiment techniques help policy makers arrive at optimal decisions, dealing with multiple outcomes and preference heterogeneity. The merits of these methods and their impact on clinical practice has been proven without doubt. Surely they cannot be replaced by the whims and diktats of politicians with limited vision.
When the solitary focus of the decision makers is popular gimmickry, healthcare, with its susceptibility to multi-attribute decision, making is a casualty. Consequently, as is the doctor patient relationship.
Think Real World Situations
Think of the young resident doctor who is not taken seriously by her patient because of her youth or gender (I was addressed as sister through nine years of my specialist clinical training in Maulana Azad Medical College, Guru Teg Bahadur hospital and AIIMS). Think of the nurse who has to perform jobs you wouldn’t want to do for a loved one. Think of them dancing in front of their patients, when they have struggled to be taken seriously all day. When they have attended to sixty eight patients instead of twenty two, each of whom have been cramped three to a bed.
Think of the irate relative who has waited six hours to see the patient, think of the patient who is waiting for his soiled bedclothes to be changed. Think of the patient recuperating from a kidney transplant, from a removed uterus, undergoing chemotherapy.
Think of the three sick people squeezed into a single bed, trying to dance, when turning a side requires complex adjustments, and a toe poking someone in the face.
Now think of the harassed team of doctors and nurses dancing to Falguni Pathak, instead of doing what they are trained to do, and indeed paid to do.
And now think of the new mother in the video with the health minister, if she would have preferred the twenty minute song and dance routine, or twenty minutes of quiet with her newborn and a nurse who could teach her how to express breast milk, or even give the baby a bath.
The answer does not need you to be a doctor, or a health ministry official.
Pseudo-scientific Babble Cannot Replace Hard Facts
The truth is we need more doctors. More nurses. More paramedical staff. We need better brick and mortar buildings to house our patients, more beds, more wards, better ICUs. We need sanitation, equipment, maintenance of equipment, responsible waste management, and on the job training and upgradation of skills for every individual that is part of the healthcare delivery system. We need more medicines, gloves, intravenous cannulas, syringes and needles. We need the political will to effect this change, and we need policy makers who will walk the talk on universal health care for all.
We, in India, are at the cusp of this transition. Band aid, populist measures may grab eyeballs on social media, and votes at the polling booth, but will do little to change the lives of the average man on the streets. Or the quality of life of the person fighting for his life in a hospital. And yet again, we’ve been let down by those who get to make decisions on our behalf.
(Dr Shibal Bhartiya is Senior Consultant, Ophthamology Services at Fortis Memorial Research Institute, Gurgaon.)
(The views expressed above are the author’s own. FIT neither endorses nor is responsible for the same.)
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